I am a Director of Clinical Services of a medicare certified home care
agency. One of the IV companies want us to do first dosing in the
home. They will provide an anaphlaxis kit with the drug. Am having
terrible time attempting to determine if this is accepted practice.
Our nurse (RN) will stay with the patient during the administration
time for the first dose, then we teach the family how to administer
the drug.  Please Help!!

homecarenurse...

I worked in the field of mental health for 20+ years, so I 
empathize with your position.

According to a pdf file available from the Princeton University
website, titled 'QUALITY ASSURANCE IN HOME DRUG INFUSION THERAPY',
which is part 7 of a 15-part series entitled 'Home Drug Infusion
Therapy Under Medicare':

"The most consistent measures of HDIT provider
 quality currently available are standards
 published by the Joint Commission on the
 Accreditation of Healthcare Organizations
 (JCAHO) and the National League for Nursing?s
 Community Health Accreditation Program
 (NLN/CHAP). However, accreditation
 through these channels can be costly to obtain,
 and many existing providers have not sought it.
 Thus, Medicare should rely on State agencies,
 acting under explicit and consistent guidelines,
 to determine initial and continuing compliance
 with any conditions of participation (COPS)
 that Medicare develops. This will undoubtedly
 mean that some providers will need to seek
 multiple certification (e.g., compliance with
 JCAHO standards for private insurer reimbursement,
 State licensure requirements for
 facility operation, and an additional set of
 COPS for Medicare reimbursement), which
 many will find burdensome. Eventually, JCAHO and
 NLN/CHAP-accredited HDIT providers
 could be granted ?deemed status? if accreditation
 standards were commensurate with Medicare?s
 COPS."

Specific to your query:

"First-Dose of Medication ? Proposed COPS required
 that the first dose of any IV therapy be given
 under the direct supervision of a physician or nurse
 who is equipped with resuscitation medication and
 equipment to treat anaphylaxis (54 F.R. 172).
 Alternatively, under a new benefit, HCFA might
 require that the first dose of infused drugs with a
 known potential for allergic reaction or other complications
 always be delivered under a physician?s
 supervision."

"The nature of the supervision could vary depending
 on the setting in which the initial dose is given.
 For example, patients who are discharged to HDIT
 from the hospital could be required to receive their
 first dose in the hospital where physicians are readily
 available. For outpatient-initiated therapy, patients
 could be required to receive the first dose in a
 physician?s office or hospital outpatient setting. For
 outpatients who are homebound, special exceptions
 could be made or, alternatively, a physician home
 visit could be required for the initial dose."
From page 16 of 23...the file is here:
http://www.wws.princeton.edu/cgi-bin/byteserv.prl/~ota/disk1/1992/9222/922207.PDF

You can also obtain the file from this page:
http://www.wws.princeton.edu/cgi-bin/byteserv.prl/~ota/disk1/1992/9222.html


A second pdf file from that page, entitled
'HOME INTRAVENOUS DRUG THERAPY: PROPOSED REGULATIONS
 UNDER THE MEDICARE CATASTROPHIC COVERAGE ACT'
notes the following about first dose:

"Condition of Participation: Protocols and Policies
 The home IV provider adheres to the following
 procedures and has written protocols and policies consistent
 with respect to the provision of home IV drug therapy
 items and services.
 (a) Standard: First dose. The first dose of any drug
 not previously administered intravenously is administered
 under the direct supervision of a
 physician or nurse who must:
 (1) remain in attendance for a time period sufficient
 to make sure that the patient is stable; and
 (2) Have resuscitation medication and equipment
 to treat anaphylaxis readily available."
From page 30 of 31...more in the file:
http://www.wws.princeton.edu/cgi-bin/byteserv.prl/~ota/disk1/1992/9222/922212.PDF

Note that these documents are from 1992, and represent
proposed protocols.


A more recent document, from the site of the State of 
North Carolina's Department of Health and Human Services'
'Division of Medical Assistance', which manages Medicare
services for that state, is titled 'HOME INFUSION THERAPY
(HIT)', and notes:

--------------------------------------------------------

7.4 Who May Provide HIT
7.4.1 Drug Therapies and Total Parenteral Nutrition
You may provide drug and TPN therapies if you are enrolled
with DMA as a HIT provider.
- Agency qualifications: Your agency must be a home care 
agency licensed by the Division of Facility Services to 
provide infusion nursing services.
NOTE: You must have service available 24 hours per day, 
seven days per week.
---------------------------------------------------------
More in the file:
http://www.dhhs.state.nc.us/dma/cc/7.pdf


While the above represents the State of North Carolina's 
policies, and may not be applicable to your specific
location, given the lack of documentation on this subject
on the internet, as evidenced by the return of only 6
results for the Google search (documented below), I would
suggest that it would be wise to play it safe in this
regard, at least until you can check with the Department
of Health and Human Services in your state. The fact that
at least one state has policies requiring enrollment with
an agency of the DHHS suggests that it would not be wise
to accept referrals for this service until you can verify
your own state's policies.


At the least, I would suggest insisting that the initial
dose be accomplished via a physician home visit if the 
therapy is initiated on an outpatient basis on a homebound
client. If they are not homebound, then it could be initiated
via a clinical appointment. This should not represent a major
difficulty for the referring agency, and will allow you time
to explore your state's requirements, if any.

Personally, I might go so far as to ask the IV company if 
they can provide the name of other agencies in your state
which have participated in the manner they are requesting
of you. This would give you the chance to contact them, in
a discreet manner, of course, and explore the topic with 
someone who is presumably knowledgeable about guidelines.


The second search, documented and linked below, returned
3,250 results for the terms:
"home infusion therapy" agency

Amidst the results there seem to be statements from several
agencies and from state policy sites, so there is a chance
that if you add your state name to the search terms, as in:
"home infusion therapy" agency Michigan
you will be able to locate information pertinent to your state,
though it may be easier to simply call the Department of Health
and Human Services in your state.


Please do not rate this answer until you are satisfied that
the answer cannot be improved upon by way of a dialog
established through the "Request for Clarification" process.

sublime1-ga


Searches done, via Google:

"home care agency" "first dose" IV
://www.google.com/search?q=%22home+care+agency%22+%22first+dose%22+IV

"home infusion therapy" agency
://www.google.com/search?q=%22home+infusion+therapy%22+agency

This is the first time that I have used these services, and I found it
to be excellent. I would recommend it to anyone. The answer was
researched and contained a great deal of information. Parts of the
response will be kept solely as reference material, the rest will be
utilized to make a policy.
Thanks for all your assistance.
Kathleen